Provider Demographics
NPI:1104336742
Name:BULKLEY, TANNER R (PA-C)
Entity type:Individual
Prefix:
First Name:TANNER
Middle Name:R
Last Name:BULKLEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 W WELLSBORO ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:16933-1411
Mailing Address - Country:US
Mailing Address - Phone:570-662-1945
Mailing Address - Fax:
Practice Address - Street 1:45 MUD CREEK RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:PA
Practice Address - Zip Code:16947-9529
Practice Address - Country:US
Practice Address - Phone:570-297-3746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-10
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA059314363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant